Reaching Highest Priority Patients

1. The risk-based screening tools and algorithms that are often used to determine PrEP eligibility don’t work and stigmatize patients.

• These papers demonstrate that commonly used risk-based algorithm and screening tools to determine PrEP eligibility (CDC guidelines, the HIRI-MSM, and the Gilead tool) did not accurately identify risk, especially among young Black men who have sex with men.
  • Lancki N, Almirol E, Alon L, McNulty M, Schneider JA. Preexposure prophylaxis guidelines have low sensitivity for identifying seroconverters in a sample of young black MSM in Chicago. AIDS. 2018 Jan;32(3):383-92.
  • Hoots BE, Finlayson T, Nerlander L, Paz-Bailey G, National HIV Behavioral Surveillance Study Group, Wortley P, Todd J, Sato K, Flynn C, German D, Fukuda D. Willingness to take, use of, and indications for pre-exposure prophylaxis among men who have sex with men—20 US cities, 2014. Clinical Infectious Diseases. 2016 Jun 9;63(5):672-7.
    
    
• This paper applies risk criteria retrospectively to a cohort of Black women living with HIV in the Southeastern United States. The author concludes that standard risk assessment criteria would have failed to identify these women as patients who would have benefit from PrEP prior to their diagnosis.
  • Tims-Cook Z. A Retrospective Assessment of Antecedent Pre-Exposure Prophylaxis Eligibility of HIV-Positive Women in the South. AIDS Patient Care STDS. 2019 Sep;33(9):384-387.
    
    
• This paper explains the ways in which HIV stigma is activated by risk assessments and screening, and may alienate patients. It also connects risk assessments to larger health programs and policies that reinforce or exacerbate stigma and can alienate patients.
  • Golub SA. PrEP Stigma: Implicit and Explicit Drivers of Disparity. Curr HIV/AIDS Rep. 2018 Apr;15(2):190-197.

2. Anticipating stigma from healthcare providers can deter patients from seeking out sexual health care, such as PrEP.

• This paper demonstrates that perceptions of LGBTQ- and/or HIV-related stigma can act as barriers to PrEP awareness and uptake.
  • Cahill S, Taylor SW, Elsesser SA, Mena L, Hickson D, Mayer KH. Stigma, medical mistrust, and perceived racism may affect PrEP awareness and uptake in black compared to white gay and bisexual men in Jackson, Mississippi and Boston, Massachusetts. AIDS Care. 2017 Nov;29(11):1351-1358.
    
    
• This paper presents data regarding barriers to PrEP use for heterosexual cisgender women in the US, who reported that communicating about their sexuality or their potential need for PrEP with health care providers was a significant barrier. The women were concerned that disclosure of HIV risk behaviors to their providers would result in judgmental responses or harsh treatment.
  • Goparaju L, Praschan NC, Warren-Jeanpiere L, Experton LS, Young MA, Kassaye S. Stigma, Partners, Providers and Costs: Potential Barriers to PrEP Uptake among US Women. J AIDS Clin Res. 2017;8(9):730.

3. Universal HIV/STI screening and PrEP education is more beneficial and cost effective than risk-based screening.

• This paper summarizes data on the failure of risk-based screening for sexually transmitted infections (STIs), and reviews the empirical evidence for the benefits and cost-effectiveness of opt-out screening strategies.
  • Hull S, Kelley S, Clarke JL. Sexually transmitted infections: compelling case for an improved screening strategy. Popul Health Manag. 2017;20(S1):S1−S11.

4. Emphasizing benefits and self-efficacy —rather than risk and fear —is more successful in motivating patients toward prevention and care behavior.

• These papers provide evidence that “objective” risk is not associated with risk perception for most patients, and may not be an effective motivator for health behavior.
  • Biello KB, Edeza A, Montgomery MC, Almonte A, Chan PA. Risk perception and interest in HIV pre-exposure prophylaxis among men who have sex with men with rectal gonorrhea and chlamydia infection. Archives of sexual behavior. 2019 May;48(4):1185-90.
  • Gallagher T, Link L, Ramos M, Bottger E, Aberg J, Daskalakis D. Self-perception of HIV risk and candidacy for pre-exposure prophylaxis among men who have sex with men testing for HIV at commercial sex venues in New York City. LGBT health. 2014 Sep 1;1(3):218-24.
    
    
• This paper presents data from four studies that conclude that encouraging individuals to examine, compare, or focus on their personal risk actually increases reactance and optimistic bias (believing oneself to be at lower risk than others).
  • Weinstein ND, Klein WM. Resistance of personal risk perceptions to de-biasing interventions. Health psychology. 1995 Mar;14(2):132.
    
    
• This paper reviews research on reactance and defensive response in health promotion, and provides evidence for the importance of self-affirmation (focusing on personal strengths and values) in reducing reactance and increasing effectiveness of health promotion messages.
  • Schüz N, Schüz B, Eid M. When risk communication backfires: Randomized controlled trial on self-affirmation and reactance to personalized risk feedback in high-risk individuals. Health Psychology. 2013 May;32(5):561.
    
    
• This meta-analysis provides evidence that interventions that heighten risk appraisals (patients’ risk perception and perceived severity of infection) are much more likely to be associated with health behavior change when they are combined with a focus on response efficacy (a belief that the behavior change will work to protect me from the illness) and self-efficacy (a belief that I can engage in the desired behavior).
  • Sheeran P, Harris PR, Epton T. Does heightening risk appraisals change people’s intentions and behavior? A meta-analysis of experimental studies. Psychological bulletin. 2014 Mar;140(2):511.